New Approach to Reducing Suicide Attempts Among Depressed Teens

A novel treatment approach that includes medication plus a newly developed type of psychotherapy that targets suicidal thinking and behavior shows promise in treating depressed adolescents who had recently attempted suicide, according to a treatment development and pilot study funded by the National Institute of Mental Health (NIMH). The study, described in three articles, was published in the October 2009 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. Continuing Education for Counselors
Background
Youth who attempt suicide are particularly difficult to treat because they often leave treatment prematurely, and no specific interventions exist that reliably reduce suicidal thinking and behavior (suicidality). In addition, these teens often are excluded from clinical trials testing depression treatments. The Treatment of Adolescent Suicide Attempters Study (TASA) was developed to address this need and identify factors that may predict and mediate suicide reattempts among this vulnerable population. A novel psychotherapy used in the study—cognitive behavioral therapy for suicide prevention (CBT-SP—was developed to address the need for a specific psychotherapy that would prevent or reduce the risk for suicide reattempts among teens. CBT-SP consisted of a 12-week acute treatment phase focusing on safety planning, understanding the circumstances and vulnerabilities that lead to suicidal behavior, and building life skills to prevent a reattempt. A maintenance continuation phase followed the acute phase.

In the six-month, multisite pilot study, 124 adolescents who had recently attempted suicide were either randomized to or given the option of choosing one of three interventions—antidepressant medication only, CBT-SP only, or a combination of the two. Most participants preferred to choose their intervention, and most (93) chose combination therapy. Participants were assessed for suicidality at weeks six, 12, 18 and 24.

Results of the Study
During the six-month treatment, 24 participants experienced a new suicidal event, defined as new onset or worsening of suicidal thinking or a suicide attempt. This rate of recurrence is lower than what previous studies among suicidal patients have found, suggesting that this treatment approach may be a promising intervention. In addition, more than 70 percent of these teens—a population that is typically difficult to keep in treatment—completed the acute phase of the therapy. However, many participants discontinued the treatment during the continuation phase, suggesting that treatment may need to include more frequent sessions during the acute phase, and limited sessions during the continuation phase.

The study revealed some characteristics that could predict recurrent suicidality, including high levels of self-reported suicidal thinking and depression, a history of abuse, two or more previous suicide attempts, and a strong sense of hopelessness. In addition, a high degree of family conflict predicted suicidality, while family support and cohesion acted as a protective factor against suicide reattempts. Other studies have found similar results, according to the researchers.

Significance
Although the study cannot address effectiveness of the treatment because it was not randomized, it sheds light on characteristics that identify who is most at risk for suicide reattempts, and what circumstances may help protect teens from attempting suicide again. In addition, the study found that 10 of the 24 suicide events occurred within four weeks of the beginning of the study—before they could receive adequate treatment. This suggests that a "front-loaded" intervention in which the most intense treatment is given early on, would likely reduce the risk of suicide reattempt even more.

What's Next
The effectiveness of CBT-SP—alone or in conjunction with antidepressant medication—will need to be tested in randomized clinical trials. In the meantime, because many suicide events occurred shortly after the beginning of the trial, the researchers suggest that clinicians emphasize safety planning and provide more intense therapy in the beginning of treatment. In addition, they note that therapy should focus on helping teens develop a tolerance for distress; work to improve the teen's home, school and social environment; and rigorously pursue coping strategies for teens who experienced childhood trauma such as abuse.

References
Vitiello B, Brent D, Greenhill L, Emslie G, Wells K, Walkup J, et al.. Depressive symptoms and clinical status during the treatment of adolescent suicide attempters. Journal of the American Academy of Child and Adolescent Psychiatry 2009;48(10):997-1004.

Brent D, Greenhill L, Compton S,Emslie G, Wells K, Walkup J, et al. The treatment of adolescent suicide attempters (TASA): predictors of suicidal events in an open treatment trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(10):987-996.

Stanley B, Brown G, Brent D, Wells K, Poling K, Curry J, et al. Cognitive behavior therapy for suicide prevention (CBT-SP): treatment model, feasibility and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(10):1005-1013.

High-Tech Treatments

By Beryl Lieff Benderly

A patient arrives in the emergency room of a small hospital in rural Tennessee in acute need of psychiatric evaluation. The attending physician lacks the specialty training to evaluate whether the patient is at risk for suicide or harm to others—requiring hospitalization—and the nearest psychiatric hospital is located more than an hour away. What should the physician do?

In the past, a mobile crisis team would have been dispatched over mountainous roads for an hour's drive to make an evaluation. Today, a high-speed video teleconference between a member of the crisis team and the patient—in real time—takes place instead.

This accelerated evaluation procedure, as described by Susan Dimmick, Ph.D., a project manager at the Oak Ridge Associated Universities, in Oak Ridge, TN, is just one of the many applications of communications technology now available to deliver mental health and substance abuse care efficiently. More than two dozen presenters shared their expertise at a recent conference, "E-Therapy, Telehealth, Telepsychiatry, and Beyond," hosted by SAMHSA's Center for Substance Abuse Treatment (CSAT) in December.

Sheila M. Harmison, D.S.W., L.C.S.W., Special Assistant to the CSAT Director, moderated the conference, which drew researchers and service providers from across the Nation and from Canada to discuss a wide range of innovative programs that use e-mail, text messaging, Web sites, and voice-over-Internet telephone in addition to video teleconferencing. These technologies overcome barriers—including distance, physical immobility, and other disabilities, and social stigma—that prevent many Americans from receiving needed mental health care. Online CEUs for Counselors
Examples of these services include:

Low-income, inner-city mothers who are in recovery from substance abuse stay in daily contact with their counseling program via e-mail.

Children in remote Alaskan villages receive mental health treatment via video teleconference from providers located in facilities hundreds of miles away.

Middle school, high school, and college students participate in personalized substance abuse interventions over the World Wide Web.

Military veterans with post-traumatic stress disorder who live on sparsely settled Indian reservations in South Dakota and Wyoming receive mental health treatment via video teleconference.

Persons undergoing cognitive behavioral therapy for anxiety disorders use palmtop computers to receive messages of reinforcement and assess their own levels of anxiety while they go about their daily activities.

Alcoholics in recovery attend group therapy sessions via streaming video and voice-over-Internet from the privacy of their homes.

"Technology can assist in our larger goal to assure a life in the community for everyone," said CSAT Director H. Westley Clark, M.D., J.D., M.P.H. The goal is not to substitute traditional treatments for mental and addictive disorders, he emphasized. "The goal is to leverage the impact of people-based services."

The use of new communications technology in treatment for these disorders is in its infancy, Dr. Clark continued. "And there does appear to be a reluctance to adopt new technology."

Qualified mental health and substance abuse professionals must make use of these new technologies. Charlatans and quacks are trying to exploit the Internet and entice the unwary into many questionable so-called therapies, Dr. Clark cautioned. "If we in the orthodox community refuse to go ‘into the ether,' others will have no compunction." In other words, research needs to go forward vigorously to evaluate the usefulness of the various technology-assisted treatment approaches. "We have to determine if e-therapy is a reliable resource for substance abuse and mental health treatment," said Dr. Clark. "I think it is."

Kathryn Power, M.Ed., Director of SAMHSA's Center for Mental Health Services, also addressed the conference. "E-health, properly researched and implemented, holds great promise for improving the mental health of millions of Americans nationwide," she said. Not only is e-health incorporated in the goals of the SAMHSA Mental Health Transformation initiative, but through the use of these technologies excellent mental health care is delivered, and research accelerated.

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High-Tech Options
As equipment and service costs continue to decrease and the availability of high-speed broadband connections continues to increase, mental health and substance abuse practitioners find themselves with many advanced options for audio, video, and text technologies.

Wireless connections now match the speed of broadband cable modems, said Brent Carter, a product development officer for Verizon Wireless, in his presentation.

Advanced encryption and other security measures allow wireless communications to meet the privacy and confidentiality requirements of mental health and substance abuse professionals, added Donald "Desi" Arnaiz, M.A., President of Virginia Systems, Inc., and an engineer for Comcast. "Everything that you require for the Health Insurance Portability and Accountability Act—HIPAA—is available to you now."

Mental health and substance abuse treatment providers and other health care providers, however, must be sure to use equipment correctly. When selecting devices, for example, they must make certain that they obtain proper security technology. "Most people don't protect their wireless systems, but care providers must take that extra precaution," said Mr. Arnaiz.

Other recommendations include choosing devices appropriate to the intended purpose and making sure that all devices work together. Correcting errors in the integration of devices is in fact his company's "biggest headache," Mr. Arnaiz said. For practitioners to have a successful program, they must also spend time learning to use the equipment.

Some adaptations in treatment techniques will also be needed to meet the demands of technology, noted Ron Adler, Chief Operating Officer of the Alaska Psychiatric Hospital. His experience with the hospital's TeleBehavioral Health video teleconferencing system convinced him that the benefits vastly outweigh the costs in both time and money. "Build this system and the funding will come and the patients will come," he urged conference participants.